ROME – Even by Mafia standards, his crimes curdled the blood.

Authorities linked him to dozens of murders in the 1990s, including the kidnapping and strangling of a Mafia turncoat’s 12-year-old son, whose body was dissolved in acid. He played a role in the murders of Italy’s two leading anti-Mafia prosecutors, in deadly bombings in Milan, Rome and Florence, and in the strangulation of a pregnant woman.

But on Monday, after 30 years on the lam and achieving infamy as Italy’s most wanted fugitive, Matteo Messina Denaro, 60, the last Italian mobster linked to a savage period in which Sicily’s “black hand” declared war on the Italian state, was quietly arrested outside a clinic in Palermo after he showed up under an alias for a medical appointment.

“Until this morning,” said Palermo’s chief Prosecutor, Maurizio De Lucia, “we didn’t even know what face he had.”

Italian officials, including the prime minister, Giorgia Meloni, who flew to Sicily to congratulate local law enforcement, immediately heralded the arrest as proof that justice, even if slow, would ultimately catch up with the country’s mobsters.

“This was a fundamental battle to win,” Meloni told reporters outside the Palermo courthouse. “This is a hard blow to organized crime.”

President Sergio Mattarella of Italy, whose brother, Piersanti Mattarella, was murdered by the Mafia in 1980 while serving as Sicily’s governor, telephoned the police and prosecutors to congratulate them.

But experts, and even local authorities like De Lucia, who called the arrest “an important contribution,” were more circumspect about what the ultimate impact would be against either the Sicilian Cosa Nostra or Italy’s other still powerful and sprawling organized crime syndicates.

“His arrest certainly weakens the Sicilian Mafia, but this is not a fatal blow,” said Lirio Abbate, a Sicilian journalist who wrote a book about Messina Denaro.

He explained that decades of relentless police action against the Sicilian Mafia – putting its leaders in prison for life without the possibility of parole, confiscating its assets, disrupting its businesses – had left it weakened.

But in its place, he said, the violent ‘ndrangheta syndicate of Calabria, and the Camorra gangs of Campania, had become the major players through trafficking in drugs, arms and other criminal activity.

“The Sicilian Mafia no longer has the far-reaching grip of syndicates like ‘ndrangheta and Camorra,” he said. “But it is a metastasis, it keeps regenerating.”

While Messina Denaro was a major player, especially as his former capos ended up dead or in prison, he could never be the boss of bosses, because, by code, the top mobster had to come from Palermo.

Still, Messina Denaro managed to control the western Sicilian province of Trapani even from hiding. Besides his blood lust, he was known for his business savvy, managing assets and infiltrating legal economic enterprises, including wind energy companies. He enjoyed protection from a wide network of mobsters, but also, the authorities said in a strong suggestion of corruption, “civilian mobsters.”

The police had few clues to track him down. Even his physical appearance was long in question. Italian news outlets have published video frames of an older man purported to be Messina Denaro traveling in a jeep across the Sicilian countryside, as well as reports of sightings across Europe.

There was speculation that he had undergone facial surgery to disguise his identity. The only evidence the police had to work with was a tape with his voice from a court in Palermo, recorded at a hearing in 1993, and a handwritten love letter he left to his girlfriend before going into hiding.

To narrow their search, the authorities produced a computer-generated image of Messina Denaro, based on his picture from a 1990s family album, and circulated it to international police forces and the news media. In September 2021, a man from Liverpool, England, was arrested in the Netherlands after he was wrongly identified as Messina Denaro. He was released days later.

This time there was no doubt, the authorities said. “He immediately confessed” when cornered during a visit to Palermo, the island’s capital, for a medical appointment, said Paolo Guido, the prosecutor who led the investigation in the Palermo office.

The authorities said they had learned through their years of investigations, and through wiretapped conversations among the mobster’s associates, that Messina Denaro suffered from a cancer that required specific hospital treatments.

The police then monitored a national database of patients seeking such treatment and over time narrowed the list down to a few names, including one they suspected to be the Mafioso’s alias.

“We skimmed down the list,” Pasquale Angelosanto, a general with the Italian Carabinieri police who commands their special division, said on Monday, adding that authorities had a hunch, but “the certainty came only this morning.”

Messina Denaro, wearing tinted glasses, a brown leather jacket trimmed in shearling, a matching hat and a Franck Muller watch that authorities said was worth about 35,000 euros, showed up with another man from the Trapani area at the hospital for his appointment.

The police had positioned themselves at the various entrances and stopped Messina Denaro on a side street. They checked his photo identity card, which looked official and said his name was Andrea Bonafede, the name they were looking for.

They asked him his name. “Matteo Messina Denaro,” he replied, the authorities said. An audio recording, apparently of him giving his name to officers, was posted online by the news outlet Corriere della Sera.

The authorities said bystanders outside the clinic applauded the police officers, their faces obscured by balaclavas, who escorted him into a black van that pulled away to a secret location. As the car left, officers hugged each other and raised their fingers in victory signs.

Guido, the prosecutor, added that like any Italian citizen Messina Denaro had a right to health care, but would now get his “in a prison.”

That is where Messina Denaro’s former bosses ended up and died.

Salvatore Riina, the “boss of bosses” responsible for a series of brutal killings of Italian prosecutors and police officers in the 1990s, was captured in 1993, also in Palermo. He had brought up Messina Denaro as a young killer with a talent for infiltrating local business and politics. Riina spent the rest of his life in prison, dying in 2017.

Bernardo Provenzano, like Riina a member of the Corleone family, pulled back from Riina’s war against the state and the killings of top investigators and journalists. He was arrested in 2006, after 13 quieter years of criminal activities.

Salvatore Lo Piccolo, a possible successor, was arrested a year later.

Only Messina Denaro remained at large. He disappeared from public life at the age of 31. His father, also a mobster, died in hiding in 1998.

Known as a ruthless boss with a taste for designer clothes and a playboy lifestyle, Messina Denaro communicated with associates through letters and handwritten messages that he avoided drafting personally. Most of his closest relatives have been arrested over the years for Mafia-related crimes, but they never betrayed him. But in recent years, police arrested associates and seized hundreds of millions in assets, depleting his capital.

In 2020, Messina Denaro was sentenced to a life term in absentia for his role in the 1992 murders of the two anti-Mafia prosecutors, Giovanni Falcone and Paolo Borsellino, and the bombings in 1993 in Florence, Milan and Rome that left 10 people dead.

Prosecutors say that he was also involved in the 1993 kidnapping of a 12-year-old boy, Giuseppe Di Matteo, to pressure the boy’s father to stop revealing Mafia secrets to the authorities. The boy’s remains were later found dissolved in acid.

“One of the most dramatic seasons of the republic’s history closes today,” Carlo Nordio, the Italian justice minister, said in a statement on Monday. “The work of Giovanni Falcone and Paolo Borsellino, and all the state’s servants who gave their life to defend democratic values, has continued.”

But in Sicily on Monday, authorities made it clear that it needed to continue still. Asked whether the arrest of Messina Denaro, who was yet to be interrogated, would set off a violent succession battle in Trapani, Guido, the lead investigator, said “until this morning,” Messina Denaro was the undisputed “boss of the province. Tomorrow we will see.”

“Obviously, the Mafia is not defeated,” said De Lucia. “It would be a big mistake to think that the game is over.”

This article originally appeared in The New York Times.